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MEDICARE RULE QUESTION
#1
Medicare presently paying for my CPAP unit. Doctor wants me to go to a BiLevel unit. Vender (Lincare) says I need a new overnight sleep test. Any comments as to your experience with Medicare when changing PAP units?
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#2
When I changed from a CPAP to Bilevel under Medicare, my experience was that the DME claimed they needed a sleep test report with results that met the accepted protocol for prescribing a Bilevel. They also needed the doctors notes before the sleep test, and the sleep test had to meet the required duration for both the first test and the titration. Also they needed an official prescription form signed by the doctor. The DME submitted this package to Medicare for approval. It took 8 weeks for DME & Sleep Dr to organize the package and 1 week for Medicare to approve it.
if you can't decide then you don't have enough data.
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#3
(06-27-2015, 03:23 PM)MobileBasset Wrote: When I changed from a CPAP to Bilevel under Medicare, my experience was that the DME claimed they needed a sleep test report with results that met the accepted protocol for prescribing a Bilevel. They also needed the doctors notes before the sleep test, and the sleep test had to meet the required duration for both the first test and the titration. Also they needed an official prescription form signed by the doctor. The DME submitted this package to Medicare for approval. It took 8 weeks for DME & Sleep Dr to organize the package and 1 week for Medicare to approve it.

*****************
Thanks for the reply. You say Medicare "approved it" in 1 week. Does that mean they did not require the re-evaluation after 30 days for adherence to the therapy? Or is changing a PAP unit a 2 step process. Approval to change and then compliance?
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#4
you don't have to have another sleep study if you already had a sleep study and was using a cpap machine but had problems. There are criteria to meet to go from cpap to vpap but it doesn't require another sleep study. I will try to find the link with the info if anyone wants it.
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#5
(06-27-2015, 04:57 PM)me50 Wrote: you don't have to have another sleep study if you already had a sleep study and was using a cpap machine but had problems. There are criteria to meet to go from cpap to vpap but it doesn't require another sleep study. I will try to find the link with the info if anyone wants it.

Would very much like the link. Yes, had a in home sleep study then a sleep lab overnight to determine pressure. Then got the CPAP unit which I have been using since early March and in full Medicare compliance. Now need to go to the BiLevel (VPAP) to address central. Really do not want another overnight sleep study.
Thanks
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#6
Bilevel machines cost more. The patient has to prove to either fail at the CPAP or show need for the bilevel. A sleep test is not needed unless there is insufficient data to back up the need. Medicare won't pay for it if the doc just wants to try it for giggles.

I found this: (E0470 is the code for bilevel and E0601 is the code for CPAP and APAP)

[quote] A recent report by NHIC, the Jurisdiction A DME MAC, regarding CERT errors provided insight as to why some of the E0470 claims under the PAP policy could have been denied. The supporting documentation regarding the physician’s face-to-face re-evaluation prior to switching from CPAP to BIPAP was lacking documentation that supports the ineffectiveness of the CPAP. In addition, the treating physician’s clinical re-evaluation did not meet the date requirements of the LCD of being no sooner than the 31st day, but no later than the 91st day after initiating therapy. Providers did not submit documentation that the symptoms of obstructive sleep apnea were improved, and there was no objective evidence of adherence to use of the BIPAP device which was reviewed by the treating physician.

Another reason that the E0470 claims under the OSA diagnosis may deny with the 50 denial is that Medicare no longer down codes to the least costly alternative, the E0601. Remember that in order for the E0470 to be covered, the patient must meet all criteria associated with the coverage of the E0601 according to policy. An E0601 must have been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.

“Ineffective” is defined as a documented failure to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings). If E0470 is billed for a patient with OSA and the criteria of the E0601 are not met, it will be denied as not being reasonable and necessary.

If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, substitution of an E0470 does not require a new initial face-to-face clinical evaluation or a new sleep test.

If an E0601 device has been used for more than three months and the patient is switched to an E0470, a new initial face-to-face clinical evaluation is required, but a new sleep test is not required. A new three-month trial would begin for use of the E0470. Coverage, coding and documentation requirements for the use of E0470 and E0471 for diagnoses other than OSA are addressed in the Respiratory Assist Devices (RAD) Local Coverage Determination (LCD) and Policy Article (PA). [/quote
PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




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#7
Just read your latest post. If you have been compliant and the bilevel (not to be confused with ASV) is "just" to treat the central events, yes, they may require another sleep study. Another beast has entered the picture. The DME should try to submit it first without it, however.

IF the supplier just happens to also be the same place that does the sleep test or in some way benefits financially from you having the sleep test, go to another supplier.
PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




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#8
(06-27-2015, 10:07 PM)PaulaO2 Wrote: Just read your latest post. If you have been compliant and the bilevel (not to be confused with ASV) is "just" to treat the central events, yes, they may require another sleep study. Another beast has entered the picture. The DME should try to submit it first without it, however.

IF the supplier just happens to also be the same place that does the sleep test or in some way benefits financially from you having the sleep test, go to another supplier.

By "compliant" I mean the 4hour/70% rule. Using CPAP, my AHI has been running around 10. Example...last night my total AI was 10.0 and my Central was 10.0 so no obstructive. Usually, central is running 85% with obstructive at 15%. Numbers all over the ball park within last week AHI 3.1 to 17.5 So with those figures, what do you think will be Medicare's position?
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#9
if you have central or complex apnea, you don't need a vpap machine.....you need an asv machine. There are things that can cause central apnea that are not really a dx of central apnea.
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#10
Beware unscrupulousness and/or incompetence.

I had a problem with a private insurance company, Anthem Blue Cross. After two sleep studies, a diagnosis of central sleep apnea and Chyne-Stokes breathing, and the prescription for an ASV machine which proved effective, Anthem Blue Cross denied my claim.

Upon appeal, they quoted their "expert" who said that the sleep study did not show OBSTRUCTIVE apnea and that it did not justify a CPAP machine.

It would seem that most on this forum know better than Anthem Blue Cross's so-called "expert" the difference between obstructive and central sleep apnea, and between CPAP and ASV.

The incompetence and lack of knowledge on the part of such a so-called " expert" would be laughable were it not for the financial implications.

Fortunately I am also covered by Medicare which has accepted the claim.

Bottom line: look out for unscrupulous insurers and their incompetent charlatans who seem bent upon denying their medical, legal and moral obligations to the insured, whether by intent or by ignorance.
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